Last updated 2026-07-25
TL;DR
In Virginia, assisted living facilities (ALFs) are licensed by the Virginia Department of Social Services under 22VAC40-73, not a health department. Licensing covers staffing ratios, resident assessments (UAI), building and fire codes, and background checks. Medicare does not pay for room and board in an ALF; Medicaid may help through the Commonwealth Coordinated Care Plus waiver for some residents.
What is assisted living?
Assisted living is a residential care option for adults who need help with daily activities like bathing, dressing, medication reminders, and meals, but who don't need the round-the-clock skilled nursing care you'd get in a nursing home. It sits in the middle: more support than home care, less medical intensity than a nursing facility. In Virginia, the formal term is "assisted living facility" (ALF), and it's a licensed category distinct from adult day care, independent senior housing, or a home health agency. The state defines it through the Virginia Department of Social Services (VDSS), which regulates ALFs under Virginia Administrative Code 22VAC40-73 [1]. That regulation is the single most important document you'll read if you're opening one of these facilities, so bookmark it now. Most ALFs house residents in private or semi-private rooms, provide three meals a day, offer some level of personal care staffing around the clock, and coordinate with outside providers (home health, hospice, physicians) for anything beyond what facility staff can legally do.
What is a group home?
A group home is a smaller residential setting, usually serving people with intellectual or developmental disabilities (IDD), mental illness, or substance use recovery needs, rather than primarily aging adults. The term gets used loosely, but licensing agencies draw real lines between it and an ALF. In Virginia, group homes serving individuals with developmental disabilities are typically licensed through the Department of Behavioral Health and Developmental Services (DBHDS) rather than VDSS, and they follow a different regulatory chapter entirely. A group home for adults needing daily living assistance because of age or physical frailty, though, generally falls under the ALF rules if it meets the definition of "assisted living facility" in the Code of Virginia [2]. The practical difference matters for licensing: if you're building a program for adults with IDD, you want DBHDS's licensing pathway, not VDSS's ALF pathway. Filing under the wrong agency wastes months. If you're unsure which category your planned population falls into, confirm with your state licensing agency before you sign a lease or start construction.
What is an assisted living facility?
Under Virginia law, an assisted living facility is "any public or private profit or nonprofit facility... that is licensed by the Board of Social Services... [and] maintains or operates... for the maintenance or care of four or more adults" who need assistance with daily living activities or who have a mental or physical condition requiring some level of care [2]. The four-or-more threshold is a real dividing line: smaller adult care arrangements may fall under different rules or exemptions, so verify your specific resident count against current statute language. Virginia sorts ALF residents into two care levels: assisted living care and, for facilities licensed to provide it, a higher level sometimes described in the regulation as care for residents needing more hands-on assistance. Regulation 22VAC40-73-450 through -470 lays out resident assessment requirements, including use of the Uniform Assessment Instrument (UAI), which every resident must have completed before or at admission to determine what level of care they actually need [1]. A licensed ALF must also have a licensed administrator (or a qualified designee under state rules), written policies covering medication management, emergency preparedness, resident rights, and a physical plant that passes both VDSS and local fire marshal inspection.
What is assisted living vs nursing home?
| Licensing agency | Virginia Dept. of Social Services (VDSS) | Virginia Dept. of Health (VDH) | |
|---|---|---|---|
| Regulation | 22VAC40-73 | 12VAC5-371 | |
| Nursing staff | Not required 24/7 in most ALFs | Licensed nurse on duty 24/7 | |
| Typical resident need | Help with ADLs, supervision | Skilled nursing, rehab, complex medical care | |
| Medicare coverage | Room/board: no | Short-term skilled stays: yes, with conditions | |
| Medicaid pathway | CCC Plus waiver (home and community-based) | Medicaid nursing facility benefit | If a resident's medical needs exceed what an ALF is licensed to provide (ventilator dependence, stage 3-4 pressure ulcers untreated by a physician's specific plan, certain behavioral health crises), Virginia regulation requires discharge planning to a higher level of care [1]. That's not a gray area; it's spelled out in the regulation's discharge and transfer criteria. |
The short version: assisted living is residential with support services; a nursing home is a medical facility with 24-hour licensed nursing care. Nursing homes (called nursing facilities in most regulation) are licensed in Virginia by the Virginia Department of Health, not VDSS, and they operate under an entirely different set of federal Medicare/Medicaid conditions of participation [3]. Here's a side-by-side to make the distinction concrete: | Feature | Assisted Living Facility (VA) | Nursing Home (VA) |
What is assisted living facility (the licensing category, explained plainly)?
If you're the one applying for a license, "assisted living facility" is a specific legal box you check on a VDSS application, and everything downstream (fees, inspection schedule, staffing math) flows from that box. It is not a marketing term; it's a regulatory status. To get and keep that status you need: an initial application to VDSS, a completed criminal background check and child/adult abuse registry check for the administrator and staff [1], a fire and building inspection coordinated with your local fire marshal and building official, and a facility that meets physical plant standards (room size, bathroom ratios, common space) laid out in 22VAC40-73 Part VII. VDSS publishes licensing fee schedules and renewal timelines; because these figures and specific dollar amounts change and vary by facility capacity, confirm current fees directly with VDSS's licensing division rather than relying on a fixed number here [1]. What doesn't change year to year is the sequence: application, background checks, plan review, pre-licensure inspection, license issuance, then ongoing annual (or more frequent, if there are complaints) inspections.
What does assisted living provide?
An ALF in Virginia is required to provide, at minimum: supervision and assistance with activities of daily living (bathing, dressing, toileting, mobility), meals that meet nutritional standards, medication management or administration consistent with the resident's assessed needs, some level of social and recreational activity, and 24-hour staff awareness of resident whereabouts and needs [1]. Beyond that floor, facilities vary a lot. Some offer memory care wings with locked units and specialized dementia programming (which comes with its own additional regulatory requirements under 22VAC40-73-320 covering safe, secure environments). Others contract with outside home health or hospice agencies so residents can stay in place as their needs increase, rather than being forced to move to a nursing home. What an ALF cannot do, by regulation, is provide ongoing skilled nursing care, manage residents who are consistently bed-bound without a hospice or home health partner involved, or handle behaviors that create a documented danger to the resident or others without a specific waiver or plan approved by VDSS [1]. Understanding that ceiling before you admit a resident saves you a very bad conversation with a surveyor later.
How to start a group home (or ALF) in Virginia, step by step
Starting a licensed adult care residence in Virginia is a sequencing problem more than a paperwork problem. Miss a step and you redo it, sometimes at real cost in construction or staffing delays. 1. Confirm your population and correct agency. IDD group homes go through DBHDS; ALFs serving aging or physically frail adults go through VDSS. Call the agency before you commit to a building. 2. Check local zoning. Group homes and ALFs both intersect with local zoning and, in many jurisdictions, get protections under the Fair Housing Act for small group homes serving people with disabilities. But building size, parking, and fire code still apply locally, so involve your county or city planning office early. See our guide on zoning and property considerations before signing a lease. 3. Draft your policy and procedure manual. VDSS reviews written policies on medication management, emergency preparedness, resident rights, admission and discharge criteria, staffing plans, and infection control as part of licensure review [1]. 4. Complete background checks. Every staff member with resident access needs a criminal history check and a search of the Virginia child abuse and neglect central registry / adult protective services records, per 22VAC40-73-70 [1]. 5. Pass the physical plant and fire inspection. Your local fire marshal and building official sign off before VDSS will issue a license. Budget real time for this; construction delays are the number one reason applications stall. 6. Submit your VDSS application with required fees. Fee schedules vary by capacity and license type, so confirm the current amount with VDSS directly. 7. Staff up before your pre-licensure inspection. You need enough trained direct care staff on the schedule to demonstrate the ratios required under 22VAC40-73-960, which sets minimum staffing based on resident count and the two care levels (assisted living care versus the higher-acuity level) [1]. 8. Pass the pre-licensure inspection and get your license. VDSS issues either a full license or, in some cases, a provisional license while final items get corrected. If you want a structured way to track every one of these steps against your state's specific checklist instead of rebuilding a project plan from scratch, the State Group Home Licensing Kit is a $299 one-time reference built around exactly this sequence: application requirements, policy manual templates, staffing worksheets, and inspection prep, organized by state.
What is the difference between assisted living and nursing home care, in practice?
Beyond the regulatory line, the practical difference shows up in daily life. In an ALF, residents generally keep more independence: they can often come and go, keep their own schedule for meals within facility hours, and receive care staged to what they actually need that day. In a nursing home, care is built around a medical model, with physician orders driving much of the daily routine. Cost structure differs too. ALFs are almost always private-pay or Medicaid-waiver funded (not the traditional Medicaid nursing facility benefit), while nursing homes bill through Medicare Part A for short skilled stays and through Medicaid's nursing facility benefit for longer-term custodial stays once someone spends down assets to meet Medicaid financial eligibility [4]. Staffing intensity is the other big divider. Nursing homes must have a registered nurse on site for at least 8 consecutive hours a day, 7 days a week, and licensed nursing staff (RN or LPN) 24 hours a day, under federal nursing home requirements [5]. Virginia ALFs have no equivalent 24-hour licensed-nurse mandate; staffing ratios instead scale to resident count and assessed care level under 22VAC40-73-960 [1].
Does Medicare cover assisted living facilities?
No. Medicare does not pay for room, board, or personal care assistance in an assisted living facility, full stop. CMS is direct about this: Medicare's long-term care coverage page states that "Medicare doesn't cover long-term care (also called custodial care)" for daily activities like bathing and dressing when that's the only kind of care someone needs [4]. Medicare will pay for specific medical services a resident receives while living in an ALF, like a covered doctor visit, physical therapy ordered by a physician, or durable medical equipment, the same way it would for someone living at home. But the facility's monthly rate for room, meals, and personal care assistance is not a Medicare-covered expense anywhere in the country, more than Virginia [4]. This catches a lot of families off guard, and it's worth explaining clearly to prospective residents' families during your admission process, because a confused family member blaming your facility for a coverage gap that's actually a federal program design issue creates unnecessary friction.
Does Medicaid pay for assisted living in Virginia?
Sometimes, through a specific program, not through Virginia's regular Medicaid state plan benefit. Virginia's Commonwealth Coordinated Care Plus (CCC Plus) program, a Medicaid managed long-term services and supports waiver, can help cover some assisted living costs for eligible members who meet both financial and functional (nursing-facility level of care) criteria [6]. This is different from Medicaid's standard nursing facility benefit, which pays directly for nursing home care once someone qualifies. CCC Plus works through managed care organizations contracted with the Virginia Department of Medical Assistance Services (DMAS), and not every ALF accepts CCC Plus members or has beds allocated to the program [6]. If you're building a facility business model, decide early whether you'll pursue CCC Plus provider enrollment. It changes your admission criteria, your billing workflow, and often your staffing needs, since CCC Plus tends to serve a higher-acuity population than a private-pay-only ALF.
How do I start a group home? (funding, staffing, and inspection basics)
Funding a group home or ALF startup in Virginia typically comes from a mix of private capital, SBA financing for the real estate and buildout, and, once operational, private-pay resident fees plus, where applicable, CCC Plus reimbursement. There is no state grant program that simply hands operators startup capital; treat any claim otherwise with real skepticism. Staffing is where most new operators underbudget. Virginia's staffing regulation (22VAC40-73-960) ties required direct care staff hours to resident census and the mix of care levels in the building, and it requires at least one direct care staff member awake and on duty at all times, with additional staff added as resident count and acuity increase [1]. Build your staffing plan and your pro forma from the regulation's actual ratios, not a guess, before you sign a lease. Inspections happen at minimum annually once licensed, and VDSS can conduct unannounced inspections in response to complaints at any time [1]. Keep your policy manual, staff training records, medication administration records, and UAI assessments organized and accessible; a disorganized inspection is a slow, expensive inspection, and repeat deficiencies can trigger enforcement action up to and including license revocation.
What should a policy manual actually cover?
VDSS reviews written policies as part of both initial licensure and ongoing compliance, and a thin manual is one of the most common reasons applications bounce back for revision. At minimum, plan for sections on admission and discharge criteria, medication management (including who can administer versus assist with self-administration), emergency preparedness and evacuation, resident rights and grievance procedures, staff training and background check documentation, infection control, and incident reporting [1]. A lot of first-time operators write a manual that sounds right but doesn't match what regulation 22VAC40-73 actually requires section by section. That mismatch is exactly what a surveyor flags. If you'd rather start from a structure built against the regulation instead of a generic template, that's the gap the State Group Home Licensing Kit is built to close: a $299 one-time set of policy manual frameworks, staffing worksheets, and application checklists organized by state licensing requirement, not generic best practice. Whatever manual you use, walk it against the current text of 22VAC40-73 yourself, or have your administrator do it, before submission. Regulations get amended, and citing an outdated provision in your own policy manual is an easy, avoidable deficiency.
Related reading
For readers comparing facility types across states or trying to understand where Virginia's rules sit relative to other jurisdictions, see our guides on assisted living, assisted living facilities, and assisted living facility licensing generally. If you're weighing whether a residential model like assisted living at home fits your market better than a traditional ALF building, or you're trying to help a family locate senior assisted living facilities near me, those pieces walk through the practical differences in more depth than we can cover in a single Virginia-focused article.
Frequently asked questions
What is assisted living?
Assisted living is residential care for adults who need help with daily activities like bathing, dressing, and medication reminders but don't need full-time skilled nursing care. In Virginia, licensed assisted living facilities (ALFs) are regulated by the Virginia Department of Social Services under 22VAC40-73, covering staffing, resident assessments, and building safety standards.
What is a group home?
A group home is a residential setting, usually smaller than an ALF, that houses people with intellectual/developmental disabilities, mental illness, or recovery needs. In Virginia, IDD-focused group homes are typically licensed by DBHDS rather than VDSS, so the correct licensing agency depends on the population you plan to serve.
What is an assisted living facility?
Under Virginia law, an assisted living facility is a facility licensed by the Board of Social Services that cares for four or more adults needing assistance with daily living activities or with a physical or mental condition requiring some level of care, as defined in the Code of Virginia and 22VAC40-73.
What is assisted living vs nursing home?
Assisted living provides residential support with help for daily activities; a nursing home provides 24-hour licensed nursing care for medically complex residents. In Virginia, ALFs are licensed by VDSS under 22VAC40-73, while nursing homes are licensed by the Virginia Department of Health under a separate regulatory chapter, 12VAC5-371.
What does assisted living provide?
At minimum, Virginia ALFs must provide supervision and help with daily living activities, meals meeting nutritional standards, medication management appropriate to each resident's assessed needs, some social/recreational programming, and 24-hour staff awareness of residents. Specialized memory care units carry additional requirements under 22VAC40-73-320.
How do I start a group home in Virginia?
Confirm the correct licensing agency for your population (VDSS for ALFs, DBHDS for IDD group homes), check local zoning, write policies matching 22VAC40-73, run background checks on staff, pass fire and building inspections, staff up to required ratios, and submit your VDSS application before your pre-licensure inspection.
What is the difference between assisted living and nursing home care?
Assisted living residents typically keep more independence and receive support staged to daily needs; nursing home residents receive care under a medical model with a registered nurse on-site at least 8 hours daily and licensed nursing coverage 24/7, as required under federal nursing home regulations.
Does Medicare cover assisted living facilities?
No. CMS states plainly that Medicare doesn't cover long-term custodial care, which includes ALF room, board, and personal care assistance. Medicare may still cover specific medical services a resident receives, like physician visits or physical therapy, the same as it would for someone living at home.
Does Medicaid pay for assisted living in Virginia?
Sometimes, through the Commonwealth Coordinated Care Plus (CCC Plus) Medicaid waiver program administered by DMAS, for members who meet both financial and nursing-facility-level-of-care eligibility. This differs from Medicaid's standard nursing facility benefit, and not every ALF accepts CCC Plus residents.
How many residents does a Virginia facility need before it's regulated as an ALF?
Virginia's Code defines an assisted living facility as one caring for four or more adults needing assistance with daily living or a condition requiring care. Smaller arrangements may fall outside that definition or under different rules, so confirm your specific situation with VDSS before assuming you're exempt.
What staffing ratios does Virginia require in assisted living facilities?
Virginia regulation 22VAC40-73-960 ties minimum direct care staffing hours to resident census and the mix of care levels in the building, requiring at least one direct care staff member awake and on duty at all times, with more staff added as resident count and acuity rise.
Who licenses assisted living facilities in Virginia?
The Virginia Department of Social Services (VDSS) licenses assisted living facilities under regulation 22VAC40-73. Nursing homes are licensed separately by the Virginia Department of Health, and IDD-focused group homes are generally licensed by the Department of Behavioral Health and Developmental Services (DBHDS).
How often are Virginia assisted living facilities inspected?
Licensed ALFs receive at least an annual inspection from VDSS, and the agency can conduct unannounced inspections at any time in response to complaints. Keeping policy manuals, staff training records, and resident assessments organized and current is the best defense against a lengthy inspection.
Sources
- Virginia Administrative Code, 22VAC40-73 (Standards for Licensed Assisted Living Facilities): Core licensing regulation covering staffing, assessments, background checks, discharge criteria, and physical plant standards for Virginia ALFs
- Code of Virginia, § 63.2-100 (definitions, assisted living facility): Statutory definition of assisted living facility as caring for four or more adults needing assistance with daily living
- Virginia Administrative Code, 12VAC5-371 (Regulations for the Licensure of Nursing Facilities): Nursing facilities in Virginia are licensed under a separate regulatory chapter by the Virginia Department of Health
- Medicare.gov, Long-term care coverage: Medicare does not cover long-term custodial care such as help with daily activities
- CMS, State Operations Manual / Nursing home requirements (42 CFR 483.35): Federal requirement for licensed nursing staff coverage 24 hours a day and RN coverage at least 8 consecutive hours daily in nursing homes
- Code of Virginia, § 32.1-325 (Administration of medical assistance services program; managed care): CCC Plus operates under DMAS's statutory authority to administer Virginia's Medicaid managed long-term services and supports program, which can help cover assisted living costs for eligible members